Incident investigation·January 24, 2025

On 1/24/2025 at 2:25PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 1/23/2025. LPA met with Executive Director, Eunice O'Farrell and informed her the reason for the visit. Based on the incident report received on 1/23/2025, med tech noticed that R1 was not in his room and was not able to be located during safety status check around 7:20PM on 1/16/2025. The door located in the back parking lot was left propped open while a vendor was bringing in their equipment. Police department was notified and R1 was located by police. R1 was transported back to the facility by R1's family/POA. During visit, LPA interviewed staff and reviewed R1's file including physician's report, service plan, care notes, and incident report. R1's physician's report stated that R1 cannot leave the facility unassisted. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.